SALT Carmelite Missionary Application
Carmelite Missionaries
Women from
18-40 years old
“Abandonment is the most serious illness of the elderly and also the greatest injustice they
can suffer. Those who helped us most to grow must not be abandoned when they need our
help, our love, and our tenderness.” - Pope Francis
Please fax the completed forms to (518) 537-4725 or scan and email to [email protected].
For questions please contact Stacey Jackson at (518) 751-8265 or email [email protected].
Select the date and location you are applying to attend:
 Dublin, Ireland | June 25-30
Last Name
First Name
 Columbus, OH | July 17-21
 Albany, NY | August 7-11
Middle Name
Preferred Nickname Date of Birth
Mailing Address
City
State
Phone Number
Email
Zip Code
List ALL Masters/Bachelors and Associates/Certifications as well as degrees in process.
Highest Level of Education Completed
Name of Institution(s)
1.) ______________________________
______________________________________________
2.) ______________________________
______________________________________________
3.) ______________________________
______________________________________________
Have you ever been convicted of a crime (felony or misdemeanor outside of traffic violations)?
(If yes, please explain)
Year of Graduation
_________________
_________________
_________________
 YES
 NO
How did you hear about the mission program?
Please list any existing or past experiences with the elderly…
Please list any ministry, work, service, or mission experience you have had…
Would you be interested in any of the following areas of service?
 Gathering life stories
 One-on-One Visiting
 Music
 Group Visiting
 Arts and Crafts
 Spiritual assistance
 Leading Reflection Group
 Participating in Exercise Group
Please list any other skills and/or interests you have that you would like to share. We are committed to utilizing participant’s skills
whenever possible.
Are you a citizen or permanent resident of the United States?  YES  NO If no, do you have a Visa/Green Card?  YES  NO
If yes to Green Card or Visa please attach copy; if no to all please provide documentation of steps being taken to secure documents.
I (PRINT NAME) _________________________________________________________________, affirm that he information
I have provided on this application is honest and accurate. I authorize the Carmelite Sisters for the Aged and Infirm, its affiliates,
its agents and its representatives to investigate or authenticate, if necessary, any of the information provided on this application.
Signature: _________________________________________________________________
Date: ___________________
Additional requirements: These requirements will be outlined in the mission packet in further detail to prepare the missionary for the experience.
SALT Carmelite Missionary Agreement
Carmelite Missionaries
“Abandonment is the most serious illness of the elderly and also the greatest injustice
they can suffer. Those who helped us most to grow must not be abandoned when they
need our help, our love, and our tenderness.” - Pope Francis
Program Terms and Conditions
1.The status of the Missionary for the duration of the
Program shall be that of a volunteer and not an employee or independent consultant.
6.No remuneration will be given by the Congregation
or the nursing home for any services rendered during
the SALT Mission Program.
2.The duration of the SALT Carmelite Missionary Program varies according to individual circumstances.
7.Participation in the SALT Carmelite Mission Program may be terminated at any time by the Missionary or by the Congregation, with no reasons needing
to be disclosed.
3.The Missionary will receive free room and board,
as well as all meals; she is expected to pay for any
personal expenses, including telephone, travel, and
all medical costs that may arise.
4.While living with the local Community, the Missionary is under the jurisdiction of the SALT Program
Coordinator. In the nursing home, she is under the
jurisdiction of the Administrator.
5. The Missionary is invited to participate in all prayers
and most meals with the local Community. Participation in certain other meals and Community functions
is left to the discretion of the local Prioress.
8. To the extent permitted by law, the Missionary agrees
to release the Carmelite Sisters for the Aged and Infirm and its SALT Mission Program,from any liability
whatsoever arising out of the Missionary’s participation in the Program, including, but not limited to, any
damage to the Missionary’s property or the property
of others and injury to the Missionary or to others,
including loss of limb or life, resulting from the Missionary’s negligence or the negligence of others, or to
others through the Missionary’s participation in this
SALT Carmelite Mission Program.
Requirements
1.The applicant must fill out a preliminary application
form received from the Coordinator of the Program,
a completed recommendation form, and participate
in a personal/ or phone interview.
2.The applicant must possess a reasonable level of maturity and health in the judgment of the Coordinator
sufficient to enable her to live away from home and
enter fully into the Salt Carmelite Mission Program.
3.Upon being accepted into the program, the
Missionary will submit :
(a)Signed Program Agreement.
(b)A completed Medical Emergency Contact Form
with copy of insurance cards
(c) Will agree to have a background check done
(if required by State)
(d) Tuberculosis test results (taken maximum one
year before start of program.)
As an applicant to the Carmelite Sisters for the Aged and Infirm SALT Mission Program, I acknowledge receipt
and review of the Program Terms and Conditions. I agree to participate in the Salt Carmelite Mission Program
in accordance with these Terms and Conditions, and acknowledge and agree with the release in this form.
Applicant
Date
Witness
Date
SALT Carmelite Missionary Recommendation
SALT Carmelite Missionary Program Sponsored by: The Carmelite Sisters for the Aged and Infirm
600 Woods Road Germantown, NY 12526, (518) 537-5000
Carmelite Missionaries
RECOMMENDATION FOR: _______________________________________________________________
The above person is applying to participate in the Serving the Aged Lovingly Today (SALT) Carmelite Missionary
Program. She has indicated that you are in a position to give us a reliable evaluation of her. A candid expression of your
opinion is necessary. All information will be kept in confidence. Thank you for your cooperation.
1.How long have you known applicant? Since:
2.A certain level of competency is needed to contribute to our mission to the elderly. In your judgment, how competent is this student as demonstrated by her work in college or in subsequent jobs?
 Extremely competent. Can always be counted on to do an excellent job.
 Very competent.
 Adequate, but not outstanding.
 Doubtful.
 Incompetent. Has failed on many occasions to perform competently.
Please describe how the applicant has demonstrated her level of competence:
3.Comment on the applicant’s ability to work with other people in a variety of settings.
4.Overall recommendation:
 I recommend this applicant without reservation for the SALT Mission Program.
 I have some reservations but feel that the applicant could benefit from this experience and contribute to the work.
 I feel this person is not suited at this time to make a positive contribution to your ministry to the Aged and Infirm.
Thank you very much for taking the time to complete this recommendation form. (PLEASE PRINT)
Your Name:
Address:
City/State/Zip:
Telephone (Day):
(Evening):
Can we contact you if we should want further clarification regarding your recommendation?
Signature:
Date:
 YES
 NO
Emergency Information
Carmelite Missionaries
In case of emergency please notify:
Name
Relationship
Mailing Address
City
Telephone (Home)
(Office)
State
Zip Code
1.Are you allergic to any medications?  YES  NO
If yes, what?
2.Are you currently taking any medication?  YES  NO
If yes, what?
What is this medication taken for?
How often do you have to take the medication?
3.Do you have any food allergies?  YES  NO
If yes, what foods?
4.Do you require a special diet?  YES  NO
If yes, please explain:
5.Are you currently under the care of a physician?  YES  NO
If yes, for what?
6.Do you have medical insurance?  YES  NO
If yes, please fill in the following, and attach a copy of your health insurance card to this form.
Name of Insurance Carrier: __________________________________________________________
Address: _________________________________________________________________________
City: _______________________________________________ State: _______ Zip: ___________
Policy #: _________________________________________________________________________
7. Have you had a tuberculosis test within one year from the start of the SALT program?  YES  NO
Please attach the results of a recent Tuberculosis test to this form.
I hereby affirm that the above information is accurate to the best of my knowledge.
Name (PLEASE PRINT): _____________________________________________________________ Date: ________________